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186 Gordon Dr/ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section /l �j 1� P. O. Boz 848/210 Hospital Street '�` / u3 i �, �� Mocksville, NC 27028 (336)751-8760 /1 IlYIPROVEMENT/OPERATION PERMIT' (/ Account #: 990002598 Tax PIN/EH #: 5862-44-1306 Billed To: Samuel Gilley Reference Name: Proposed Facility: Residence Subdivision Info: Location/Address: 186 Gordon Drive -27006 Property Size: see map ATC Number: 3365 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type & #People #Bedrooms J #Baths_ Dishwasher Garbage Disposal: ❑ Washing Machin Basement w/Plumbing: 173Basement/No Plumbing: El Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �� Design Wastewater Flow (GPD) Site: New ❑ Repair ❑ System Specifications: Tank Size/ GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30f.m. to 9:x30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of insta lation. Telephone # is (336)751-8760.**** F Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990002598 Billed To: Samuel Gilley Reference Name: Proposed Facility: Residence ATC Number: 3365 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5862-44-1306 Subdivision Info: Location/Address: 186 Gordon Drive -27006 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW R ONSTRUCTION IS V LID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: IF CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. r Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: D '� 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & LS Davie County Health Department " r_ Environments/Health Section F� ✓ rJ� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIR1111111111111111NrV DA VIE z .Tqt y& AITH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ,I/`0/k`l 51�� Contact Person Mailing Address _ )�'e, &!px / ��/ Home Phone�yL2� �n '> City/State/ZIP _"t 5 /rJ l�1�/j`.Ll.�� G Q? -1 usiness Phone 3,3l ?22' �%,3 loe6, — 2. Name on Permit/ATC if Different than Above Mailing Address City/Stat 3. Application For: YSite Evaluation zimproXne' ATC ❑ Both 4. System to Service: X House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 # Bathrooms iU Dishwasher 11 Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. /I`f Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well [I Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo If yes, what type? I***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED I BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Properly Dimensions: Tax Office PIN: #_ 5,0i ;Z �5" �'19"> 4 Property Address: Road Name ,1 0Z City/zip{,[ If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocicsville) to PROPERTY: Date Property Flagged: C J This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by Siit6le�.LL�y to conduct all testing procedures as necessary to determine the site suitabijity. DATE a - 3- �-� SIGNATU$E'.��IWV-- THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of'the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. 2 S X Invoice No. 3 3 S,ff U N w 86 333 5619 F., (245) N 358 I (4.53A) 7947 (11.40A) 9883 ........GORDON DRIVE....... _. _..._ ._............ ........ (207) A 1) (193) D70000004903 (1.72A) 1.70A (1.69A) 8397 "' 1306 M 2396 � C 158 50 200 194 512 0 N (2.36A) 1085 458 00 CD (1.94A) N 1846 (5.30A) 5840 .1 SR 1448 (18 5) (1.67A) 4374 (172) I (7 (1.72A) 6384 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002598 Tax PIN/EH #: 5862-44-1306 Billed To: Samuel Gilley Subdivision Info: Reference Name: Location/Address: 186 Gordon Drive -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3_1 4 5 6 7 Landscape position L, Sloe % HORIZON I DEPTH G Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure / Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE C SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: �&" `"< OTHER(S) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) ■ ■ ■■E■■■■ ■■■M■E■ ■■■■E■■ ■EMEM■■ ■■■■■■■ ■M■■■■■ ■MEMM■■ ■■■NESS ■NES■M■ ■EEE■■■ ■MM■M■ ■■■MO■ ■EM■■■ ■■■■S= ■E■E■E■EM■■E■E■■ ■■E■E■■■■■■■■EM■ ■■E■E■E■E■E■E■E■ ■N■E■E■E■ENSOMEN ■■■■■■EMM■M■E■E■ ■■MME■M■MEM■■EM■ ■■■■■■■EE■■MMM■■ ■■MMM■■■/i►ZlME■■■ ■ ■M■■■■■■M■■■■■■ ■MEMMEME■■■M■■■ ■M■■■MM■■■M■■■■ ■o■ ■E■ ■■■■■E■ ■E■MOM■ ■■M■■■■ ■■■mums ■E■EEE■ ■E■sus■ ■E■N■■ ==mmum■ ■■■■MM■ ■E■■MM■ ■■■■/■■ ■E■ESE■ ■E■■EM■ ■E■EM■ ■EEmi: ■E■N■■ ■E■NE■ ■ENNE■ ■ENNE■ ■M■I:iE■ ■ ■EN■■■ ■E■E■■ ■■■■n■ ■M■ME■ ■EN■■■ ■E■N■■ ■NONE■ ■ IMME■ ■EN■■■ ■■EM■■M■ ■E■E■ME■ ■EMEMEM■ ■■■■■ME■ ■EM■■EM■ ■EEE■■M■ ■■EEE■E■ ■E■EM■■■ ■EO■■EE■ ■EEE■■M■ ■■E■E■E■ ■EEM■■E■ ■E■E■"m ■ENE■E■■E■ ONEEMEMOME ■EM■■EEE■■ ■MM■ ■■M■ ■O■■ ■■M■ ■M■■ MEMO soon ■■■■ NONE ■ ■ ■ February 7, 2003 Samuel A. Gilley P.O. Box 1903 Kernersville, NC 27284 Re: Site Evaluation/ 186 Gordon Drive Tax Office Pin : #5862-44-1306 Dear Client(s): As requested, a representative from this office visited the aforementioned site on February 5, 2003 Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Aza &' 6;;4aA. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df